Traumatic Occlusal Forces Flashcards
Other conditions affecting the
periodontium
(5)
Systemic diseases
Periodontal abscess or
periodontal/ endodontic lesions
Mucogingival deformities and
conditions
Traumatic occlusal forces
Tooth and prosthesis related
factors
Occlusal Trauma (OT) Diagnosis
Injury resulting in tissue changes within the attachment
apparatus (periodontal ligament, cementum and supporting
bone) as a result of occlusal forces (etiology)
Occlusal Trauma (OT) Diagnosis
Occlusal forces = !
Teeth
Occlusal Trauma (OT) Diagnosis
May occur in an
intact periodontium or in a reduced
periodontium affected by periodontal disease
What is a ‘reduced’ periodontium?
Based on an in vitro study, reduced is loss of —%
of bone support
> 60
AAP World Workshop 2017
Occlusal trauma and excessive*
occlusal forces
Questions asked:
(2)
- Does occlusal trauma (OT) initiate periodontal disease?
- Does occlusal trauma lead to progression of existing
periodontal disease?
AAP World Workshop 2017
Occlusal trauma and excessive*
occlusal forces
Questions asked:
* Does occlusal trauma (OT) initiate periodontal disease?
* Does occlusal trauma lead to progression of existing
periodontal disease?
*Point of interest-title of workshop includes —, but terminology is
changed to —
excessive
traumatic
Why the Change?
Research performed for over 100 years but used different
animal models and experimental design (magnitude,
direction and location of forces)
* Sheep
* Human necropsy
* Beagles
* Squirrel Monkeys
Overall, past studies showed lack of ‘cause and effect’.
i.e. Occlusal Trauma (OT) did not cause pocket formation or
lead to loss of connective tissue.
Parts of the Periodontium
Affected by Occlusal Forces
- Cementum
- PDL
- Alveolar Bone Proper
The gingiva and junctional epithelium are not
affected by occlusal forces.
Classification of Traumatic Occlusal Forces
on the Periodontium (2017)
1. Occlusal Trauma
(3)
A. Primary occlusal trauma
B. Secondary occlusal trauma
C. Orthodontic forces
Occlusal Trauma
Variables:
(4)
- Direction of force.
- Magnitude of force.
- Duration of force.
- Frequency of occurrence
Trauma From Occlusion
1. Considered to be —.
2. Forces of occlusion — the adaptive capacity
of the periodontium
pathologic
exceed
Primary Occlusal Trauma 2017
Traumatic occlusal forces applied to a tooth or teeth
with normal periodontal support
With Primary occlusal trauma, clinically may see
adaptive mobility (does not progress)
Primary Occlusal Trauma 2017
Example is
‘high’ restoration with mobility resolving
following reduction.
Secondary Occlusal Trauma 2017
Injury resulting in tissue changes from normal or
traumatic occlusal forces applied to a tooth or teeth
with reduced periodontal support
* May be seen as progressive mobility &/or pain
Trauma from Occlusion
A. Compression side
(4)
- PDL space is reduced as fibers are compressed
- Loss of fiber orientation
- Increased capillary permeability, rupture of blood
vessels and hemorrhage into PDL perivascular
spaces (edema) - Resorption of alveolar bone proper (root resorption
if severe) then widening of PDL space
Minor Trauma (from occlusion)
(5)
- Increased capillary permeability, dilation
- Edema, disturbed fluid exchange
- Vascular damage with stasis, clotting, thrombosis
- Lowered periodontal resistance?
- Accompanying tissue effects, usually minor
Trauma from Occlusion
B. Tension side
(4)
- Increase in PDL space
- Rupture of PDL fiber bundles
- Compression of PDL blood vessels and
hemorrhage into perivascular spaces - Deposition of new alveolar bone and decrease in
PDL space (If severe, cemental tears)
Severe Trauma (from occlusion)
(5)
- Crushing (pressure) injury - necrosis at furca, alveolar crest
- Extravasated RBCs, hematoma, necrosis, vascular damage
- Well-defined necrosis, including PDL, cementum, bone
- Degenerative changes (hyaline, mucoid, liquefaction)
- Repair from PDL, endosteal cells, bone marrow, Haversian
systems (rear resorption)
Term: Primary Occlusal Trauma
Definition:
Manifestation:
Traumatic occlusal
forces applied to tooth
or teeth with NORMAL
periodontal support
Adaptive mobility (not
progressive or
pathologic)
Term: Secondary Occlusal Trauma
Definition:
Manifestation:
Normal or traumatic
occlusal forces applied
to a tooth or teeth with
reduced periodontal
support
Progressive mobility
(may exhibit mobility
and/or pain on
function)
Consider splinting?
Problem
The lesion of Occlusal Trauma can only be confirmed
—, so must use
other surrogate indicators
(2)
histologically by block section biopsy
- Clinical
- Radiographic
Proposed clinical and radiographic indicators of
occlusal trauma
(11)
- Fremitus (palpable or visible
movement of a tooth when subject to
occlusal forces) - Thermal sensitivity
- Mobility
- Discomfort/pain on chewing
- Occlusal discrepancies (working
&/or balancing interferences) - Widened periodontal ligament space
- Wear facets
- Root resorption
- Tooth migration
- Cemental tear
- Fractured tooth
Fremitus
A palpable or visible movement of a tooth when
subjected to occlusal forces.
Clinical Signs/Symptoms of
Occlusal Trauma
1. — of affected teeth.*
2. Radiographic evidence of —
3. Positive Hx of —
4. — teeth.
5. Evidence of working and/or balancing
side —
Mobility
thickened PDL.
clenching or bruxism.
Missing or tilted
occlusal interferences
Mobility Assessment
1=
2 =
3 =
first distinguishable sign of
movement > than normal
(physiologic)
movement which allows crown to
move 1 mm from its normal position
in any direction
tooth may be rotated or depressed
in alveoli
Mobility Assessment
Must use
2 rigid instruments, NOT fingers
Occlusal Discrepancies
(2)
- Working &/or balancing interferences
- Wear facets (BUT may be normal part of aging!)
- Working &/or balancing interferences
(3)
- Evidence of occlusal slide in CR or CO
- Evidence of occlusal interferences in protrusive
mandibular movement - Extremely steep cuspal inclines
Bruxism
Grinding, clenching or clamping of the teeth.
* The force may damage tooth or attachment
apparatus
Signs & symptoms of bruxism:
(7)
- Increased mobility
- Pulpal sensitivity / bite tenderness
- Non-masticatory / excessive occlusal
wear - Dull percussion sound
- Muscle tenderness / spasm /
hypertrophy / tiredness (am) - TMJ pain / jawlock
- Audible sounds
Other Manifestations of Traumatic
Occlusal Force
(3)
- Malocclusions
- Tooth migration
- Fractured teeth
Radiographic Signs
(5)
- Widened PDL space
- Thickening of lamina dura
- Vertical (angular) bone loss
- Furcal bone loss
- Alveolar radiolucency &/or
condensation
Periodontal Ligament Dimensions
* PDL thickest at —
Less at —
* Varies with —
apices & alveolar crest (0.20
mm);
mid-root (0.15 mm)
functional / force status of tooth
Problems with surrogate indicators
* Existing — may contribute to
mobility
* — may be due to ‘normal’ function rather
than parafunctional habits (bruxism, clenching,
grinding)
* Altered — of teeth may be due to other factors
loss of attachment
Wear facets
vitality
Indications for Occlusal Adjustment
(4)
- Traumatic injuries / soft tissue injury; food
impaction - Increasing mobility or fremitus
- Parafunctional habits
- In conjunction with orthodontic /
orthognathic therapy
Contraindications to Occlusal
Adjustment
(5)
- Absence of a pre-treatment diagnosis
- As prophylactic therapy or only treatment
for periodontal disease - As primary therapy of bruxism
- Severe extrusion or malpositioned teeth
- When periodontal inflammation has not
been controlled
Effect of Periodontal Treatment on
Mobility
Tooth mobility negatively affects outcome of
Tooth mobility generally will decrease once
periodontal therapy and maintenance
inflammation is controlled
‘Recommendations’ from Workshop
* If see signs and symptoms of occlusal trauma and patient’s comfort
and function are impacted then perform
occlusal adjustment in
conjunction with periodontal therapy
- Evaluate and record — before, during and after treatment
occlusion
- Treatment of occlusal trauma ‘may
slow the progression of
periodontitis and improve the prognosis
Orthodontic Forces
Animal studies- certain orthodontic forces can
adversely affect the periodontium and cause (4)
root
resorption, pulpal disorders, gingival recession
and alveolar bone loss
Orthodontic Forces
Observational studies-
teeth with a reduced but
healthy periodontium (no inflammation) may
undergo successful tooth movement without
compromising periodontal support
Occlusal Hyperfunction
1. — increase in occlusal force.
2. Considered to be a — adaptation
and not a — entity
Slight
physiologic
pathologic
Clinical Symptoms of Occlusal
Hyperfunction
1. Increase in number and diameter of —
2. Increased —
3. Increased density and thickness of —
4. Radiographic evidence of —.
5. Slight or undetectable tooth —
collagen fiber bundles in PDL
width of PDL.
alveolar bone proper (lamina dura).
osteosclerosis
mobility
Occlusal Hypofunction
(3)
- A mild weakening of the tooth supporting
structures due to lack of physiologic
stimulation. - Considered to be a physiologic adaptation
and not a pathologic entity. - Can only be diagnosed by histology
Occlusal Hypofunction
1. — in number of PDL fiber bundles
but normal orientation.
2. — physiologic turnover and
remodeling of alveolar bone.
3. — of PDL space.
4. — change in tooth mobility
Decrease
Decrease
Narrowing
No
Disuse Atrophy
Total removal of occlusal forces resulting in
lack of the level of physiologic stimulation
required to maintain normal form and
function.
Physiologic adaptation and not considered
pathologic
Clinical Symptoms of Disuse Atrophy
(3)
- Radiographic evidence of decreased width
of PDL space. - Increased tooth mobility is always present.
- Absence of occlusal antagonist.
Disuse Atrophy
1. — of the principle fiber
bundles of the PDL.
2. — PDL width.
3. — in number of bony
trabeculae, i.e., localized osteoporosis
Loss of orientation
Narrowed
Significant decrease
Trauma From Occlusion
Trauma from occlusion, in the absence of
inflammation, does not cause:
(3)
- gingivitis
- periodontitis
- pocket formation
The Role of occlusion in the Dental Implant and
Peri-implant condition: A Review. Graves CV,
Harrel SK et al.,
Open Dent J 2016, Nov 16;10:594-601
“Several articles demonstrated that occlusion and
occlusion overload could detrimentally affect the
— condition, while other articles did not
support these results.”
peri-implant
The Role of Occlusion in Implant Therapy:
A Comprehensive Updated Review.
Sheridan RA, Decker AM et al.
Implant Dent 2016 Dec; 25(6):829-838
PubMed database review 1950 to September 2015
* Findings
- Recommendations still lacking regarding implant
occlusion but include - Mutually protected occlusion with
- Anterior guidance
- Wide freedom in centric relation (decrease cuspal
inclines) - Reduce occlusal overload (more implants, less
cantilevers) - Close monitoring for parafunctional habits
Harrell communication on AAP Forum
2019
Performed comprehensive lit review for textbook chapter on occlusion in
the failure of implants most articles were case reports/opinion articles
& related to prosthetic failure.
Recommend
(2)
- Occlusal adjustment (prior to implant restoration)
- Hard acrylic bite guard in all cases (or where parafaunctional habits
are suspected)
Conclusions
Traumatic Occlusal Forces (TOF)
* No evidence that this causes —
* Limited evidence (animal and human) that it
causes —
* Observational studies that TOF may be
associated with severity of —
* Animal model-
* Human-
periodontal
attachment loss in humans
inflammation in the periodontal ligament
periodontitis
may increase alveolar bone loss
no evidence
Traumatic Occlusal Force and
Relationship to
(2)
- Non carious cervical lesions
(NCCL’s) /Abfraction - Recession
Traumatic Occlusal Force(s) and
Abfraction
NO EVIDENCE that TOF causes
non-carious cervical
lesions (NCCLs). Most studies used finite element
analysis (not clinical)
NCCLs may result from abrasion, erosion or corrosion
Recession
EVIDENCE from observational studies that Traumatic
Occlusal Force does NOT cause gingival recession
Abfraction
No credible clinical evidence to support existence of
abfraction
Therefore there can be no evidence implicating
abfraction as cause of recession!
